Fill and Sign the Read the Information Before You Begin Completing This Statement

Claimant’s Statement (for Non -represented claimant only) Read the information before you begin completing this statement. Please be advised that the Division of Workers’ Compensation cannot represent any party in a claim for benefits. The Division of Wo rkers’ Compensation cannot furnish legal counsel or represent the interest of any party in any claim. An attorney can advise you as to the complexities of settlements and rights which may be applicable. In choosing to represent yourself, you assume the sole burden of proceeding and bear any risk associated with the settlement requested. How to Complete This Form The Division of Workers’ Compensation will use the information you give on this statement in considering your proposed settlement. Print or type your answers. A reference to “you, ” “your,” or “claimant” means the person who was injured at work. Answer all the questions in each section with your response or “none,” “does not apply ,” or “don’t know .” Check answers where a space or box is provided. If you need more space for any of your answers, use Section 5 Section 1- Information About the Claimant A. Name ______________________ ______ ______________________ (First) (MI) (Last) B. Current Age _________ C. Daytime phone number (_______) _______- ________ ( area code ) D. Email address:___________________________________ E. Date of Injury _______/_______/_______ Month Day Year Section 2 – Information about The Injury A. State the p art(s) of the body injured: ________________________________________________________________ B. Have you received a P ermanent Partial Disability rating? ___yes ____no If yes, please give the percent of disability _______% If more than one doctor has given a PPD rating state below: ______________________________ ___________% Do ctor’s name % of disability C. Any work restrictions given by the doctor? ______yes ______no If yes, please state the restrictions given and include whether they are Temporary or Permanent: _______________________________________________ ________________ ________________________________________________________________ ________________________________________________________________ Section 3 – Information About Your Education A. Last year of schooling completed in grades K -12 ______________ B. Did you graduate from High School? ______yes ________no Check one: Diploma? _______ GED? ____ C. List any additional schooling, job training, degrees, certificates, or licenses you have received: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Section 4 – Information on Work History. Please briefly lis t jobs held during the past 10 years: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Are you unable to do any of these jobs? _______yes _______no If yes, explain which jobs and why: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Are you currently working? ___________yes ___________no Is this the job you held when injured? ________yes __________no (If no to either question, explain) ________________________________________________________________ ________________________________________________________________ Have Your Earnings changed because of injury? _________yes _____no If yes, explain. ________________________________________________________________ ________________________________________________________________ Section 5- Additional Information You Want to Share: (attach up to 2 additional pages, if necessary) ______________________________________________________ _________ ________________________________________________________________ ________________________________________________________________ Section 6 – Certification and Signature I certify that I have answered these questions to the best of my abili ty and that any statements written are accurate and true to the best of my knowledge. Signature:_______________________________ Date: ____________________ (Print name here): ________________________ _____ ( 07- 12) 14- 0163